This is a blog by a former CEO of a large Boston hospital to share thoughts about hospitals, medicine, and health care issues.

Friday, February 02, 2007

Excelling in Hospital Information Systems (not only for geeks!)

OK, I am here to brag again. Use your browser to forward to the next blog if you don't want to see this.

There is a lot of talk about how hospitals are in the age of the abacus when it comes to information systems. BIDMC is not. Our CIO, Dr. John Halamka, and his team have built a set of administrative and clinical applications in our place that lead the country. Here is part of his semi-annual report, the part dealing with just the clinical matters. Tell me if your place comes anywhere close to this!

As I have done in previous years, the following is a mid-year progress report about our FY07 major IS initiatives.

Clinically, we are focused on quality improvement, patient-centered care and pay for performance projects.

We have built and gone live with a Perioperative Management System for Operating Room scheduling and workflow enhancement in all BIDMC surgical locations. In December, we added Specimen Tracking to the OR to ensure all tissue removed from patients is delivered to pathology, analyzed, and reported back to the appropriate clinician. In the Spring, we will add OR charging by exception and later this year, we will implement perioperative provider order entry (POE) in the OR holding area and begin work on adding large LCD dashboard displays to our ORs.

We have implemented our ambulatory medical record, webOMR, to all HMFP and BIDPO practices eligible for a hospital-based electronic health record. webOMR now includes e-Prescribing and we are one of the first hospitals in the country to automate prescription routing. In the next few weeks, ePrescribing will include formulary checking to ensure that clinicians choose medications that are covered by the patient's insurance. We have also implemented an automated results notification system that alerts ordering physicians to new laboratory, pathology and radiology results. We have chartered a Users Group to prioritize future webOMR enhancements.

We have launched a new intranet portal at which offers single sign on and remote access to most applications, news feeds and customizable links for research, clinical, education, human resources and departmental content. We are working with Corporate Communications to replace the BIDMC external website and add many advanced web features.We have developed a strategy for providing a hosted electronic health record for non-owned clinicians at non-BIDMC sites of service. This system includes the ability to view all BIDMC clinical data and order tests from within a commercially developed electronic medical record/practice management system, eClinicalWorks.

We designed and implemented an innovative Oncology Management System, which automates all aspects of chemotherapy ordering and treatment. We have also developed a medication reconciliation system which enhances patient safety and complies with JCAHO best practices. To help improve inpatient vaccination rates, we developed a new system of prompts and reminders for influenza vaccine, and we will enhance the existing system for pneumovax. Also, to improve safety, we developed and deployed an adverse events tracking system in collaboration with Healthcare Quality. As part of our ongoing work to automate inpatient documentation, we will begin work this year on a suite of automated clinical documentation tools.

We are completing our MetaVision Critical Care System pilot this year and if the pilot is successful, we will replace our existing critical care application. This new system provides multidisciplinary clinical charting and tools for measuring quality. Examples of such measurement include Central line infection, ventilator associated pneumonia, and real time alerts based on clinical protocols.

We have obtained funding for expansion of the automated labor and delivery application, OBTV, to the Emergency Department and will be installing the upgrade this Spring. This will further enhance patient safety by providing remote real-time fetal tracing surveillance and alerting of ED patients by Labor & Delivery experts.

We have completed the first phase of our Positive Patient ID wrist band project and currently 80% of all patients have bar codes to ensure positive identification when receiving medication or giving blood samples. We will pilot a process to bar code employee badges and plan the bar coding of medications this year. These initiatives lay the foundation for the creation of an electronic medical administration record in the near future, replacing the current paper process and implementing bar coding technology in support of patient safety initiatives already underway.

We are implementing a new lab system which includes chemistry, hematology, pathology, blood bank and microbiology lab support. This new system will be one of the first systems to utilize the bar coded wristbands generated by the Positive Patient ID initiative. It will track specimens from the time they are ordered to the time results are made available for viewing and will streamline lab operations. Results generated from inpatient glucometer measurements will also be available on-line.

We are implementing and supporting several department specific quality registries as prioritized by the new Registry Committee.

We are in the final stages of selecting a new radiology information system (RIS). We’re also working collaboratively with all departments at BIDMC to develop an enterprise-wide image management (PACS) strategy. Areas of focus include identification of technical commonalities among various systems that could create economy of scale benefits for the medical center, comprehensive back-up and disaster recovery planning for all PACS data and a consolidated approach to ensure all images are available to all clinicians.

Within Radiation Oncology, initiatives underway include interfacing electronic charting software to the medical center’s billing system to ensure accuracy, implementing WebOMR within the department to reduce paper charting errors, and aligning all our IS efforts to ensure we provide optimal support for the entire cancer care process.

We have implemented the 3M System for Case Management, DRG Nurse Reviewers, Audit/Denial Management and will soon implement abstracting for coding. The system enables case managers to use Interqual criteria to make decisions about medical necessity and continued stay on inpatients and observation visits. The DRG Nurse Reviewers using 3M have the ability to e-mail physician queries directly from the system regarding documentation improvement for coding.

The Lab Scanning Pilot went live in November 2006 for scanning Lab Requisitions viewable via a web application on the intranet portal. The next step is to implement Dermatology clinical documentation and Heme/Onc external lab reports scanning for viewing in webOMR. Our eScription voice recognition team is implementing new portable handheld devices and template processing in Orthopedics.

Medical Library services collaborated with Health Information Management to standardize medical abbreviations at BIDMC. We are currently investigating how to integrate "Do Not Use" and "Approved" abbreviations into webOMR.Enough! Now, you see why I love this guy.

Implemented means "in service, with real people using it every day to do their work." Selected means that there has been a working group of users and our IT folks who have specified system requirements and have picked a vednor or have chosen to write the application ourself. Users are involved every step of the way to make sure the systems deliver what THEY want in a way THEY can use it.

Dunno any answers to technical questions. Maybe John will join in and tell you.

As for budget, I don't recall offhand, although I will say we are very efficient and get a lot more per dollar invested than lots of other folks.

"We build and buy systems. The core system is self developed and is a service oriented architecture with an entirely web-based user interface. It communicates with purchased systems via web services and Hitsp compliant standards - www.hitsp.org

"Every project I mentioned has a go live data of this year except the lab and radiology systems which are next year.

"Our budget is 2% of the operating budget of the hospital. That's at the low end of the range for academic health centers."

Fair enough, I am impressed. Certainly not the norm for a hospital to muster enough development resources to build their own system. Kudos for that and even more Kudos for each open source software package you used (it is the future...)

This is an impressive list, but I would have been even more impressed if the theme had been "Operating problems and how I used IT to solve them" or "How I used IT to improve performance and reduce cost."

Kudos should go not to those who can list the most applications implemented, but to those who can show the most improvements achieved through the use of IT.

Paul. No one will dispute that John's done a great job nor that BIDMC has been an innovator ...especially in patient information systems (Caregroup's PatientSite). However, I have a comment and a question.

The comment is that no one has really figured out how to take a simplified version of all this into the heartland of smaller community hospitals where there are no John Hamalkas and John Glasers (or budgets to go with them). But the role of IT generally has been to let smaller companies compete with big ones. Do you think that the work you're doing is "transferable" especially as so much is home grown.

The question: one of John's colleagues from that other place, Blackford Middleton, lamented to a group about 18 months ago that a patient from Mass General could physically "cross the street" and be admitted at BIDMC, but couldn't easily bring their electronic records with them.

Is that still the case, and is progress being made there? or do you like it like that!

With respect to the "new intranet portal" mentioned in the report, may I ask what specifically was the solution? Was that entirely an internal development effort or was that a vendor or open source selection? Dr. Halamka seems pretty thorough in all IT offerings, so any details on how the intranet was received would be great to know.

From John:We built the portal ourselves with freely available .NET components - we did not buy Sharepoint, Microsoft Content Server or any other proprietary product. It includes a very flexible framework for customization, RSS feeds for news, single sign on, and web services which link to many of our workflow dashboards.

Who does the charges for the cases in the OR? Is it the OR nurses' responsibility to do charges during the case or does someone else do this? Further, what charge system is used in the OR to perform this duty? Thanks from another OR nurse.

"The plan is for the nurse to enter the charges at the end of the case instead of filling out the paper that they use today. There will then follow a reconciliation process where the information is reviewed by the clinical advisors before being released for billing."

Any comments yet on electronic disease reporting to MDPH or the local boards of health? The information when it does arrive (on paper...) is usually missing the doctor information and no phone number for the patient! Any thoughts on how to move this along?